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T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
The majority of simple fractures of the radial head are stable, even when displaced 2 mm. Articular fragmentation
and comminution can be seen in stable fracture patterns and are not absolute indications for operative treatment.
Preservation and/or restoration of radiocapitellar contact is critical to coronal plane and longitudinal stability of the
elbow and forearm.
Partial and complete articular fractures of the radial head should be differentiated.
Important fracture characteristics impacting treatment include fragment number, fragment size (percentage of
articular disc), fragment comminution, fragment stability, displacement and corresponding block to motion, osteopenia, articular impaction, radiocapitellar malalignment, and radial neck and metaphyseal comminution and/
or bone loss.
Open reduction and internal fixation of displaced radial head fractures should only be attempted when anatomic
reduction, restoration of articular congruity, and initiation of early motion can be achieved. If these goals are not
obtainable, open reduction and internal fixation may lead to early fixation failure, nonunion, and loss of elbow and
forearm motion and stability.
Radial head replacement is preferred for displaced radial head fractures with more than three fragments, unstable
partial articular fractures in which stable fixation cannot be achieved, and fractures occurring in association with
complex elbow injury patterns if stable fixation cannot be ensured.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this
work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has
had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in
this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
http://dx.doi.org/10.2106/JBJS.J.01989
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years postoperatively. However, clinical and functional outcomes were not superior to those obtained following nonoperative treatment of these injuries in previous series. The
magnitude of displacement and articular surface involvement
that is acceptable and reliably portends an acceptable clinical
and functional outcome is not known. However, at increasing
magnitudes of displacement, complex patterns and associated
injuries are more common and should be strongly suspected.
Unstable Partial Articular Fractures
Unstable partial articular fractures of the radial head are defined
by gross displacement, periosteal disruption, metaphyseal bone
loss, radiocapitellar articular incongruency, malalignment and
impaction, block to elbow and forearm motion, and the presence
of associated elbow or forearm fracture-dislocation patterns38.
Involvement of the anterolateral quadrant of the radial head articular surface is often seen following posterolateral subluxation
or dislocation. This is the nonarticular portion of the radial head,
and the lack of subchondral bone may make it more prone to
fracture and comminution and less able to provide support for
fixation34. Open reduction and internal fixation along with softtissue repair is indicated to restore stability of the elbow when
primary ligamentous stabilizers have been disrupted.
Operative Exposure
When operative fixation of an isolated radial head and neck
fracture is required, a lateral surgical approach is generally utilized for exposure. A lateral skin incision at the elbow is centered
over the lateral epicondyle and extends from the anterior aspect
of the lateral column of the distal part of the humerus along
the midaxial line of the radial head and proximal part of the radius. Several deep muscular intervals may be exploited, including
the Kocher interval49 between the anconeus and extensor carpi
ulnaris muscles or the Kaplan interval50 between the extensor
carpi radialis longus and extensor digitorum communis. Alternatively, the extensor digitorum communis may be split as
described by Hotchkiss26. The exposure can often proceed through
the traumatic defect in the lateral structures. An arthrotomy is
performed anterior to the lateral ulnar collateral ligament to
prevent creating posterolateral rotational instability. Bain et al.51
advocated a lateral Z step-cut ligament-sparing capsulotomy
anterior to the lateral ulnar collateral ligament at the level of the
anular ligament to avoid overtensioning if one elects capsular repair during closure. Distal exposure of the proximal radial shaft
requires elevation of the extensor-supinator complex and protection of the posterior interosseous nerve. Tornetta et al.52 found
that in only one (2%) of fifty arms did the posterior interosseous
nerve lie directly on the radius and that the average distance (and
standard deviation) from the radial head to the origin of the
posterior interosseous nerve was 1.2 1.9 mm, with the takeoff
being proximal to the radial head in thirty-one cases. In a cadaveric
study, Schimizzi et al.53 found that the mean distance between the
posterior interosseous nerve and the radiocapitellar joint in neutral, supination, and pronation was 44.5, 40.8, and 48.2 mm, respectively. On the basis of these data, the posterior interosseous
nerve may be safer during exposure with forearm pronation. An
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Fig. 1-A
Fig. 1-C
Fig. 1-B
Figs. 1-A and 1-B Preoperative anteroposterior (Fig. 1-A) and lateral (Fig. 1-B)
radiographs demonstrating a displaced radial head and neck fracture.
Fig. 1-D
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Fig. 2-A
Fig. 2-B
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arable radial head fracture with no radiographic evidence of instability on radiographs75, intraoperative assessment for ligament
injury, particularly of the ulnar collateral ligament and interosseous membrane, is required26,75. The prevalence, severity, and
clinical sequelae of proximal migration of the radius after the
excision of isolated fractures of the radial head remain controversial75-77. While biomechanical alterations at the ulnotrochlear
articulation are seen following resection72,78, Antuna et al.79 reported no correlation between satisfactory functional outcomes
and the degree of arthrosis at the time of long-term follow-up
after acute radial head resection in young patients with isolated
fractures without associated instability.
Radial Head and Neck Fractures Associated with Complex
Elbow and Forearm Injuries
Unstable, displaced Mason Type-2 and 3 fractures of the radial
head and neck are often a component of complex fracture-
Fig. 3-A
Fig. 3-B
Figs. 3-A and 3-B Preoperative anteroposterior (Fig. 3-A) and lateral (Fig.
3-B) radiographs demonstrating an unstable, complete articular fracture
Fig. 3-C
Fig. 3-D
Figs. 3-C and 3-D Postoperative radiographs made after radial head replacement and suture anchor repair of the avulsed lateral collateral ligament complex.
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dislocation patterns about the elbow and forearm62. These patterns include the spectrum of posterolateral rotatory instability
injuries (displaced partial or complete articular fractures of the
radial head in conjunction with rupture of the lateral collateral
ligament and terrible triad injuries), valgus injuries of the elbow
(tensile failure and disruption of the ulnar collateral ligament
complex followed by lateral column fracture), posterior transolecranon fracture-dislocations and posterior Monteggia80 variants (Bado81 Type-2 injuries), and longitudinal instability of
the forearm (Essex-Lopresti82 lesions). Although series have been
of a retrospective nature, it has been consistently demonstrated
that restoration of stable radiocapitellar contact and the lateral
column buttress is essential to optimize outcomes following
these complex elbow and forearm injuries66,83-89. In these injuries,
prosthetic replacement of the radial head is preferred over
suboptimal fixation because the radial head and neck will bear
increased axial, coronal, and sagittal plane forces because of the
associated soft-tissue disruptions. Suboptimum fixation may
result in early or late failure. In addition, greater disability and
inferior clinical outcomes have been reported in patients who
receive delayed treatment of radial head fractures associated
with complex fracture-dislocation patterns90.
Postoperative Care
When rigid fixation is achieved or prosthetic replacement is
performed, a long arm posterior plaster splint or bulky compressive dressing is worn until the first office visit between seven
and ten days postoperatively. Active and active-assisted range of
motion of the elbow and forearm is then initiated on the basis
of the stability of fixation and assessment of the radiographs.
In the presence of concomitant ligamentous or functionally
equivalent osseous injuries, a ligament-specific protocol may
be instituted with mobilization in pronation (lateral-sided injury)91 or supination (medial-sided injury)92. Shoulder abduction and varus stress on the elbow is avoided when lateral-sided
injury is present. Strengthening exercises are initiated when there
is clinical and radiographic evidence of fracture union. Delayed or
protected mobilization with a hinged elbow brace may be necessary when there is concern about elbow stability following complex fracture-dislocations. A hinged brace with gradual reduction
of the extension block helps to maintain radial head congruity
against the capitellum and to protect soft-tissue repairs. Extension
splinting may be used to address flexion contracture. Static progressive splinting can be effective for regaining ulnohumeral motion20,93, although flexion contracture release may be needed.
Overview
Fractures of the radial head and neck continue to represent
technical challenges to the upper extremity surgeon. A better
appreciation of the spectrum of injuries that may be seen at
the proximal part of the radius, whether in isolation or in
conjunction with associated complex elbow and forearm injury patterns, continues to emerge. Headless or variable-pitch
compression screws buried in a subarticular fashion allow for
stable fixation of the articular disc in select cases of partial
head fractures. Complete articular fractures and combined
radial head-neck fractures may be addressed with a lowprofile periarticular implant that allows for a single fixation
construct in cases of neck or shaft extension. Fixed-angle lowprofile periarticular implants help to address technical challenges created by metaphyseal comminution and bone loss in
the radial neck, radial head-neck impaction, and osteopenia.
Evolution in radial head prosthetic designs to better match the
dynamic in vivo relationships in the radiocapitellar and
proximal radioulnar joints may improve outcomes following
radial head arthroplasty.
Displacement, fragment stability, the magnitude of articular comminution of fracture fragments, and associated
complex injuries are essential components to consider in the
decision-making process. The concept of fracture fragment
stability is often undefined in current studies of elbow fractures. Recognition of fragment instability may help to elucidate the optimum treatment of Type-2 fractures and may
prove to be an important determinant of outcomes following
radial head fractures35.
Current evidence supports the treatment of isolated,
minimally displaced or stable Mason Type-2 partial articular fractures without associated block to motion with early,
progressive active range of motion. Displaced, partial articular fractures creating mechanical impediment to motion are
treated with open reduction and internal fixation. Isolated, unstable and multifragmentary fractures of the radial head and
those associated with complex elbow fracture-dislocation and
ligamentous injuries are usually treated with radial head arthroplasty. Open reduction and internal fixation is performed
when a stable fixation construct that allows for radiocapitellar
contact and early motion is obtainable. Fixation failure, nonunion, osteonecrosis, recurrent instability, and poor functional
outcomes are seen following open reduction and internal fixation of these complex fractures if fixation is tenuous. Severe
articular fragmentation, displacement with loss of cortical contact, metaphyseal bone loss, and the size and quality of the
fracture fragments make open reduction and internal fixation
technically challenging. The optimum fracture for open reduction and internal fixation will have three or fewer articular
fragments without impaction or deformity, each of sufficient
size and bone quality to accept screw fixation, and little or no
metaphyseal bone loss. The exposure that is selected will be
determined on the basis of the constellation of osseous, ligamentous, and soft-tissue injuries. n
David E. Ruchelsman, MD
Dimitrios Christoforou, MD
Jesse B. Jupiter, MD
Department of Orthopaedic Surgery,
Hand and Upper Extremity Service,
Massachusetts General Hospital/Harvard Medical School,
55 Fruit Street, Yawkey Center,
Suite 2100, Boston, MA 02114.
E-mail address for D.E. Ruchelsman: druchelsman@partners.org.
E-mail address for J.B. Jupiter: jjupiter1@partners.org
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